Individual
JEROME WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
100 DIPLOMAT WAY, THIBODAUX, LA 70301-4314
(985) 316-6483
Mailing address
100 DIPLOMAT WAY, THIBODAUX, LA 70301-4314
(985) 316-6483
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
—
—
103TF0000X
Family Psychologist
38-3949990
LA
103TF0000X
Family Psychologist
—
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
NA
—
LA
Enumeration date
01/10/2020
Last updated
01/10/2020
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